NIL Reporting Form

This form is for student-athletes who will be or have been compensated for the use of their names, images and likeness for promotional purposes.

Reminders:

Student-athletes are responsible for understanding and ensuring compliance with state law/executive action and/or institutional policy related to name, image and likeness.
To the extent required by state law/executive action and/or institutional policy, student-athletes should report information related to their name, image and likeness activities.
Reported information should be kept on file in a manner consistent with state law/executive action and/or institution policy.

Due date:

CURRENT STUDENT-ATHLETES: Within five 72 hours of the date of signature on the contract by the student-athlete.
INCOMING/TRANSFER STUDENT-ATHLETES: Within 30 days of matriculation at MCC for all agreements entered into prior to coming MCC.

First Name *

Last Name *

Student ID Number *

Date of Birth *

Email address *

Sport(s) you compete in *

Describe the name, image and likeness activity. What are/were the terms of the agreement or transaction? *

When was the agreement signed? *

When will/did the activity begin and end? *

How will you be or how were you compensated for participating in the name, image or likeness activity? *

How much is your compensation? *

List all parties to the agreement or transaction, other individuals and entities and professional service providers:

Name of person/entity, role, and contact information *

Name of person/entity, role, and contact information

I affirm, to the best of my knowledge:
- I have confirmed that this activity is consistent with state law/executive action and institutional policy. I understand that I am responsible for determining whether this activity is consistent with state law/executive action.
- To the extent required by state law/executive action and/or institutional policy, I have provided complete and accurate information regarding any and all activities involving use of my name, image and likeness, including compensation arrangement and information about individuals and entities involved in the activity.
- Compensation was/is related to actual use of my name image and likeness and was/is not contingent on enrollment at a particular institution or a substitute for pay for athletics performance.
I acknowledge that my institution, or a designee of my institution, may review the accuracy of this information, and I consent to any investigation, review, or audit. I acknowledge that inaccurate or incomplete disclosure, or failure to cooperate could support a reasonable conclusion that compensation I received constituted an inducement to attend or remain enrolled at a specific school, a substitute for pay for athletics performance or participation, or an otherwise illegitimate source of compensation for use of my name, image and likeness.

* required field